Hysterectomy should generally be considered only as a last option in treating women with heavy menstrual bleeding, says guidance for the NHS in England and Wales issued this week by the National Institute for Health and Clinical Excellence (NICE).
The guidance advises that hysterectomy should be considered only when heavy menstrual bleeding has a severe effect on a woman's quality of life and other treatments are not suitable or not working—or for a woman wanting to stop her periods completely. It can also be considered for women who fully understand the risks and benefits and who ask for a hysterectomy or for those not wanting to have a child.
Mary Ann Lumsden, professor of gynaecology and medical education at the University of Glasgow and chairwoman of the guideline development group, said, “In the early 1990s it was estimated that at least 60% of women presenting with heavy menstrual bleeding would have a hysterectomy to treat the problem, often as a first treatment and without discussion of any alternative options. It is fundamental that all women with heavy periods know there is now a range of treatment options and [that] many don't require surgery.”
If investigations indicate no obvious problems with a woman's womb, the guidance recommends the levonorgestrel releasing intrauterine system (LNG-IUS) as the first line drug treatment, providing that long term use (at least 12 months) is anticipated.
Second line drug options include tranexamic acid, non-steroidal anti-inflammatory drugs, or combined oral contraceptives, followed by norethisterone (15 mg daily from days 5 to 26 of the menstrual cycle) or injected long acting progestogens.
Where surgery is indicated, endometrial ablation is considered preferable to hysterectomy in women with heavy menstrual bleeding and without other symptoms and where the uterus is no bigger than a 10 week pregnancy. The guidance recommends that dilatation and curettage should not be used as a therapeutic treatment.
Where fibroids are the cause of heavy menstrual bleeding, the surgical options recommended by the guidance are uterine artery embolisation, which blocks the blood supply to the fibroids and causes them to shrink, and hysteroscopic myomectomy, a procedure in which a hysteroscope is used to remove the fibroids.
Women who are offered hysterectomy should discuss the implications of the surgery fully before a decision is made. This discussion should include the effects on sexuality and on fertility, bladder function, need for further treatment, treatment complications, the woman's expectations, alternative surgery, and the psychological effects.
Where hysterectomy is performed the preferred route is vaginal, with abdominal surgery as the second line option—the decision taking the assessment of the individual patient into account. Specialists should be competent in the surgical procedures offered. If a specialist is not trained in undertaking a particular treatment, the guidance recommends that the woman should be referred to another specialist with this training.
Nice Clinical Guideline 44: Heavy Menstrual Bleeding is at www.nice.org.uk/CG44.